Suicide

Concerns summary A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.

Concerns summary Family information regarding self-harm risk was disregarded when denied by the patient, and care coordinators lacked dedicated time for contemporaneous note-taking. Carers' mental health needs were also not integrated into long-term plans.

Concerns summary Poor communication protocols meant Hannah's GP was unaware of her non-engagement with mental health services. The engagement policy lacked clarity on re-booking appointments and escalating non-attendance, allowing newly referred patients to slip through the system.

Concerns summary Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk of critical information loss.

Concerns summary Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.

Concerns summary A critical gap in mental health service provision in Norfolk and Waveney meant high-risk patients did not meet criteria for available support, leaving them without appropriate care.

Concerns summary There is an inadequate provision of mental health support for prison officers, which needs urgent review.

Concerns summary A vulnerable patient was prematurely discharged into homelessness from a mental health unit without proper planning, medical review, or adequate risk assessment, failing to follow Care Programme Approach guidelines.

Concerns summary The mental health service lacked a reliable system for direct, tailored communication with service users regarding their referral status and plan, failing to account for their specific needs.

Concerns summary Accident and Emergency patient notes, particularly for mental health concerns, were not regularly updated or reviewed, indicating a need for improved documentation processes and staff training.

Concerns summary Inadequate application of the Care Programme Approach (CPA) policy and untimely allocation of care coordinators for patients discharged from inpatient mental health settings.

Concerns summary Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.

Concerns summary The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.

Concerns summary There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental health teams.

Concerns summary The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.

Concerns summary National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.

Concerns summary Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.

Concerns summary Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.

Concerns summary Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.

Concerns summary HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.

Concerns summary Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.

Concerns summary Shooting range staff lack consistent national training in identifying abnormal behaviour or conducting emergency response exercises, which could significantly improve safety protocols for participants.

Concerns summary A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.

Concerns summary A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.

Concerns summary Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.